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Pressure Injuries Caused by Medical Devices and Other Objects: a Clinical Update

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Pressure Injuries Caused by Medical Devices and Other Objects: a Clinical Update WOUND WISE 1.5 HOURS CE Continuing Education A series on wound care in collaboration with the World Council of Enterostomal Therapists Pressure Injuries Caused by Medical Devices and Other Objects: A Clinical Update A review of practical resources, including mnemonics, to aid in prevention and identification. ABSTRACT: At the April 2016 National Pressure Ulcer Advisory Panel (NPUAP) consensus conference, termi- nology and staging definitions were updated and two definitions were revised to describe pressure injuries (PIs) caused by medical devices or other items on the skin or mucosa. Here, the authors discuss the etiology and prevention of PIs resulting from medical and other devices, the frequency of such injuries, and the bodily sites at which they most often occur. They provide an overview of the current NPUAP guideline, highlight im- portant risk factors, and explain why mucosal PIs cannot be staged. Keywords: medical device–related pressure injuries, mucosal pressure injuries, National Pressure Ulcer Ad- visory Panel, pressure injury, pressure injury staging, pressure ulcer, SORE mnemonic, DEVICE mnemonic ressure injuries (PIs), formerly known as bed- pressure ulcer was replaced by pressure injury to sores, decubiti, pressure sores, or pressure ul- underscore the fact that PIs may be present even Pcers, have been a nursing concern since the when the skin is intact, and the definitions of medi- time of Florence Nightingale. In April 2016, the Na- cal device–related PIs (MDRPIs) and mucosal mem- tional Pressure Ulcer Advisory Panel (NPUAP) shone brane PIs were revised.1 (See Figure 1 for a depiction a spotlight on this issue by convening a consensus of intact, undamaged skin.) The NPUAP currently conference in which associated terminology and defines MDRPIs as PIs that “result from the use of staging definitions were updated. (The 2016 staging devices designed and applied for diagnostic or ther- definitions can be found on the NPUAP website: apeutic purposes,” noting that on the skin such PIs www.npuap.org/resources/educational-and-clinical- tend to take on “the pattern or shape of the de- resources/npuap-pressure-injury-stages.) The term vice” (see Figure 2) and “should be staged using 36 AJN ▼ December 2017 ▼ Vol. 117, No. 12 ajnonline.com By Barbara Ann Delmore, PhD, RN, CWCN, MAPWCA, IIWCC-NYU, and Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON, FAAN the [NPUAP] staging system.”1 The NPUAP defines mucosal membrane PIs as those “found on mucous membranes with a history of a medical device in use Hair shaft at the location of the injury,” noting that mucosal Duct of PIs cannot be staged because histologic characteris- sweat gland tics of mucosal tissue do not allow clinicians to dis- tinguish partial from full-thickness tissue loss.1, 2 In championing the prevention of PIs caused by Epidermis Horny layer Cellular layer medical and other devices, the NPUAP has raised Sebaceous awareness of the injury such devices can inflict on gland the skin or mucosal membranes and has clarified Muscle that erects hair shaft Dermis that the classification system used to stage PIs of Sweat gland the skin cannot be used to describe PIs of the mu- Hair follicle cosal membranes (see Skin and Mucosal Pressure 3-9 Vein Injuries ). The Joint Commission and the National Nerve Database of Nursing Quality Indicators have ad- Subcutaneous Artery opted the new terminology, and discussions between tissue the NPUAP and the Centers for Medicare and Med- icaid Services (CMS) about incorporating the revised Figure 1. Layers of intact, undamaged skin. © 2013 Lippincott Wil- language are under way.10, 11 At press time, the CMS had recognized that a variety of terms are used in liams and Wilkins. All rights reserved. both long-term care facilities and long-term care hospitals to describe and document PIs. The CMS has further acknowledged that “it is acceptable to The general scope of PI frequency is reflected in code pressure-related skin conditions in Section M the International Pressure Ulcer Prevalence (IPUP) [on skin conditions in the Minimum Data Set] if dif- Survey, which has been collecting data annually from ferent terminology is recorded in the clinical record, participating facilities since 1989, when it was intro- as long as the primary cause of the skin alteration is duced by the medical technologies provider Hill-Rom. related to pressure.” 9, 12 Nevertheless, setting-specific Its large database pulls information from a wide vari- standards can be seen in some CMS terminology ety of care settings, including acute, long-term, long- and in staging and coding instructions (see Pres- term acute, rehabilitative, and home care. The most sure Injuries and CMS Documentation Regula- recent IPUP survey report provided data on 918,621 tions9, 12-15). patients treated in U.S. facilities over a 10-year period Although the change in terminology from pres- and showed a decline in the prevalence of acute care sure ulcer to pressure injury has been controversial, facility–acquired PIs from 6.4% to 2.9% between in this article we focus instead on the etiology and 2006 and 2015; but the report did not specify the prevention of PIs resulting from medical devices proportion of PIs related to medical or other devices.17 and other objects. We also discuss the frequency of device-related PIs and the bodily sites at which they most often occur. We also review the evidence pre- sented in current guidelines and identify the risk fac- Nurses should consider all tors that may increase a patient’s vulnerability to device-related PIs. patients with a medical device to ETIOLOGY AND FREQUENCY OF DEVICE-RELATED PIs be at risk for medical device– All PIs are believed to result from pressure or a com- bination of pressure and shear forces, though other factors, such as microclimate, nutrition, perfusion, related pressure injuries. comorbidities, and the condition of soft tissue, may influence a patient’s ability to tolerate pressure.1, 16 As our understanding of PI etiology has evolved, aware- For various reasons, there is relatively little infor- ness and concern about PIs caused by medical and mation available on the risks or frequency of device- other devices has increased in clinical practice. Sur- related PIs. First, some clinicians do not acknowledge prisingly, however, research on the frequency of such them as PIs, either because they’re unaware of the injuries is limited. NPUAP terminology or they disagree with the NPUAP [email protected] AJN ▼ December 2017 ▼ Vol. 117, No. 12 37 captured in prevalence or incidence data. Addition- ally, though the Glamorgan Scale acknowledges medi- cal devices as potential PI risks, the Braden Scale, commonly used to assess PI risks in adults, does not take such devices into consideration.18, 19 The extent to which medical devices cause PIs may, however, be gleaned from several studies that have specifically reported on these data. For example, in 2009, VanGilder and colleagues sampled 86,932 U.S. acute care patients and found that 1,631 of the 17,911 PIs (9.1%) were device related, with 785 of these facility acquired.20 Device-related PIs were most commonly found on the ear (20%), sacral– coccyx region (17%), heel (12%), and buttocks (10%). Black and colleagues reported on a subset of data (collected during eight quarterly PI incidence and prev- alence studies conducted at the Nebraska Medical Figure 2. A pressure injury resulting from the hub Center) that included 2,079 adult patients who were PI free on admission to a critical care, step-down, or of an IV line that was secured directly to the skin. medical–surgical unit.21 Of the 2,079 patients, 113 Notice the imprint on the skin that matches the de- (5.4%) developed hospital-acquired PIs, 39 (34.5%) of sign of the hub. Photo © 2015 BA Delmore. which were related to medical device use. When prob- ability was calculated, patients who were using a medi- cal device were found to be 2.4 times more likely to and believe that device-related PIs or at least muco- develop a PI of any kind than patients who were not. sal device-related PIs should be categorized differ- An analysis by Apold and Rydrych of hospital- ently. Consequently, these types of PIs are not always ized patient data collected through Minnesota’s Table 1. Key to the NPUAP, EPUAP, and PPPIA Strengths of Evidence and Strengths of Recommendation Strengths of Evidence A The recommendation is supported by direct scientific evidence from properly designed and imple- mented controlled trials on pressure ulcers in humans (or humans at risk for pressure ulcers), provid- ing statistical results that consistently support the recommendation. (Level 1 studies required.) B The recommendation is supported by direct scientific evidence from properly designed and imple- mented clinical series on pressure ulcers in humans (or humans at risk for pressure ulcers) providing statistical results that consistently support the recommendation. (Level 2, 3, 4, 5 studies.) C The recommendation is supported by indirect evidence (e.g., studies in healthy humans, humans with other types of chronic wounds, animal models) and/or expert opinion. Strengths of Recommendation Strong positive recommendation: definitely do it Weak positive recommendation: probably do it No specific recommendation Weak negative recommendation: probably don’t do it Strong negative recommendation: definitely don’t do it EPUAP = European Pressure Ulcer Advisory Panel; NPUAP = National Pressure Ulcer Advisory Panel; PPPIA = Pan Pacific Pressure Injury Alliance. Note: Level refers to the “level of evidence” assigned to a study based on study design and quality. Reprinted with permission from the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline.
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